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Coding

Skin Lesion Excision

 

Rule 

Included (Global) 

Not Included

(i.e. coded separately) 

Skin Lesion Excision (Benign or Malignant) 

Excision size reported is the greatest diameter of the lesion plus the narrowest margin to adequately excise it on either side of the lesion.

Example:

18mm SCC is removed with 3mm margins all around = 24mm excised diameter 

*Dog ears or additional tissue removed to smooth closure is not included in size of lesion excision, but is included in length if separate coding for intermediate or complex repair is performed 

Simple repair 

Cannot be coded in combination with adjacent tissue transfer, intermediate repair or complex repair.  

If these are performed, they are coded by the method of reconstruction without separate reporting of the lesion excision 

Wound Repair

*By definition, does not create a secondary (donor) defect 

 

 

Rule 

Simple Repair 

Wound repaired in a simple, single layer (includes buried sutures) 

Intermediate Repair 

Wound repaired in layers without extensive debridement OR simple single layer closure that requires extensive debridement before closure 

Complex Repair 

Wound repaired in layers requiring undermining or debridement before closure 

Flap Reconstruction

*Requires creating a secondary (donor) to reconstruct the recipient defect 

 

Rule

Included (Global)

Not Included

(i.e. coded separately)

Adjacent tissue transfer 

Size reported includes the area of the primary defect plus that of the secondary defect made for the tissue advancement: 

If the primary defect (A) is 4 cm2 and the secondary defect (B) created by elevation of the flap is 20 cm2, the total defect (A +B) is 4+20 = 24 cm2.   

Includes local random pattern flaps (e.g. rhomboid) as well as defects already presents (e.g. Mohs defects) 

Elevation, transfer of the flap 

Excision of a skin lesion (benign or malignant) 

Direct closure of the secondary (donor) defect 

  • Excision of tissue lesion types (soft tissue masses or bone resections). Example: neurofibromas are coded separately as they are soft tissue masses 
  • Mohs 
  • Debridements, wound excisions, wound preparations 
  • Reconstructive closure of the donor site if not done directly 

Island flaps 

  1. Cutaneous flaps 
  2. Transposed into a nearby but not immediately adjacent defect 
  3. Based on an axial vessel 

Excision of a skin lesion (benign or malignant) 

Direct closure of the secondary (donor) defect 

 

Formation of a direct or tubed pedicle, with or without transfer 

If transferred, location is based on the recipient site 

If delayed, location is based on the donor site 

  

Microsurgery

Indocyanine green (spy) 

  • Reported separately as: 
    • 15860 – Intravenous injection of agent (e.g. fluorescein) to test vascular flow in flap or graft 
  • Do code as: 
    • 92240 – indocynanine-green angiography (includes multi-frame imaging) with interpretation and report 
    • Used for indocyanine green in retinal surgery 

Breast Implants

  • Capsulotomies cannot be coded separately for implant replacement as it must be performed to carry out the procedure 
  • Capsulectomies are coded separately because they are above and beyond what is necessary to perform an implant exchange or removal 
  • Fat grafting is coded separately 

Fat Grafting

  • 20926 – tissue grafts, other (e.g. paratenon, fat, dermis) 

    • Includes: 
      • Harvest of the fat graft by any method (e.g., syringe, suction- assisted lipectomy, incision) 
      • Closure of the donor site, if indicated, with appropriate dressing 
      • Processing of fat graft material 
      • Injection of fat graft into recipient site 
      • Dressing of recipient site 
      • 90 days of routine postoperative care 
    • Not anatomic site or volume specific 
      • EXAMPLE: 50cc of fat graft to the face and 500cc of fat grafting to the thigh are coded the same 
    • If fat graft is placed into two or more separate sites (e.g. each breast), a modifier is used to indicate a separate procedure with the same code (20926-59) 

Facial Fractures

  • Each anatomic site reduced and fixated gets coded separately 
    • Example, ORIF of ZMC and orbital floor are coded separately 
  • Repair of “complicated” fractures requires repair through multiple incisions and may breech special structures (e.g. neurovascular foramen)